Healthcare Provider Details

I. General information

NPI: 1982167748
Provider Name (Legal Business Name): ANDREW JOSEPH OTTO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8849 CHARINGTON CT
PICKERINGTON OH
43147-9549
US

IV. Provider business mailing address

339 E MAPLE ST
NORTH CANTON OH
44720-2593
US

V. Phone/Fax

Practice location:
  • Phone: 740-412-6757
  • Fax:
Mailing address:
  • Phone: 330-498-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.012143
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: